The Role of Medical Evidence in North Carolina Workers’ Compensation Cases

Your medical records will play a critical role in the success of your workers’ compensation claim, even in cases where it is obvious that you have suffered a debilitating injury as the result of a workplace accident. Your medical evidence will determine how much compensation you receive and for how long. To discuss your claim and the medical evidence you will need, contact a workers’ compensation attorney for guidance. 

What You Need to Prove in Your Workers’ Compensation Claim

It is important to emphasize that you will have to prove your claim in order to receive your workers’ compensation benefits. This is easier in some cases than in others. A worker who has lost a limb in a major industrial accident may qualify for workers’ compensation while a worker who suffers a soft tissue injury from overexertion may have a harder time proving their case. Both workers will have to submit documentation proving their claim. Specifically, injured workers need to prove the following: 

1. That their injury occurred in the performance of their job duties, and
2. That their injury limits their ability to do their job. 

Proving the first element requires documenting the facts surrounding the accident that caused your injury — how the accident happened, when, and what you were doing. In most workers’ compensation cases, this is fairly easy to do. 

The second element is where the medical evidence comes in. While you only need to prove that your injury is work-related once, medical evidence will play an ongoing role throughout the life of your claim. 

If you have suffered a serious injury, you may need someone to help you gather the medical evidence you need. A friend or family member can help, as can an experienced workers’ compensation attorney. 

Insufficient Medical Evidence Can Lead to a Denial of Your Claim

Insufficient medical evidence is one of the most common reasons why workers’ compensation claims are denied. This can happen for several reasons, such as the following: 

• You do not have adequate documentation of the extent of your injuries
• Your documentation does not explain how your injuries limit your ability to perform your job
• Your documentation does not provide a prognosis
• Your documentation does not identify a link between the accident and your injury

Denials happen because workers don’t realize they have to include this documentation with their claims. In other situations, the documentation itself may be unclear. The doctor may have neglected to establish a link between the accident and your injury or explain how your injury limits your ability to do your job. A worker’s compensation attorney can review your medical evidence, work with your doctor to make any necessary clarifications, and ensure they are included with your paperwork supporting your claim. 

How Medical Evidence Will Play an Ongoing Role in Your Case

Recovering from a serious injury takes time. There can be setbacks and complications along the way that cause recovery to take longer than expected. In other cases, you may heal more quickly than the doctor expected. 

At some point, you will need to be reevaluated by a doctor to determine whether you should continue to receive benefits or whether you are able to return to work and to what extent. This means that additional medical documentation will be submitted to support one of the following situations: 

• You remain injured and unable to work and, therefore, should continue to receive benefits
• You have fully recovered and are cleared to return to your prior job, full-time
• You have recovered enough to return to work but with restrictions (can only work part-time on or light duty) 

Maximum Medical Improvement

At some point during a claim, the doctor may determine that the worker has reached “maximum medical improvement” or “MMI” for short. Depending on the case, MMI may be a full recovery from the worker’s injuries. In other cases, MMI may mean that the worker will never fully recover and will always have some kind of partial or total disability. Whatever the determination, the doctor will need to submit medical evidence supporting their determination. 

Determining MMI isn’t always a clear-cut case. You may disagree with your doctor that you are not capable of further recovery or to what extent you can return to work. For example, your doctor may have cleared you to work full-time in a physically demanding role, but you are still experiencing considerable pain and discomfort. In these situations, you are entitled to seek a second opinion. If you choose to challenge the original doctor’s determination, you will need medical evidence that supports your position. If you disagree with your doctor’s MMI determination, a workers’ compensation attorney can help you gather the evidence you need. 

Change in Condition

There are also situations where workers can experience a deterioration in their condition after they have received workers’ compensation benefits. This may entail unexpected complications, additional medical treatment, and further limitations on their ability to work. If you are able to pursue a claim for additional compensation, you will need clear medical documentation to support your claim. 

Your Medical Records Prior to Your Injury

Lastly, it is important to note that the insurance company will want to review all of your medical records, including those records that existed prior to your injury. As a result, they will be aware of any pre-existing injuries or health conditions you may have had. This does not mean that your claim will be denied, but it could cause complications. A workers’ compensation attorney can work with your doctor to make sure that your current medical records clearly delineate between your current injury and your pre-existing injury or health condition so that a fair determination can be made with regard to your workers’ compensation benefits. 

Talk to a Workers’ Compensation Attorney at Martin & Jones Today

We have been helping injured workers receive their workers’ compensation benefits for more than 30 years. If you have been injured on the job and need help with your workers’ comp claim, contact us today at 800-662-1234 to schedule a free consultation.